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recurance

Lack of basic first aid training and CPR among prison officers

Closely relatedConfidence 0.90 · high12 reports · 2015–2026No published response to an earlier report One-page brief (print or PDF)

His Majesty's Prison and Probation Service received 12 coroners' reports about this hazard between 25 Mar 2015 and 21 May 2026.

They came from 12 different coroners in 11 coroner areas. A similar concern was raised again 11 times after the first warning.

A published response was found for 10 of the 11 earlier reports, stating 8 specific actions.

12
reports
12
different coroners
2015–2026
years
0.90
lowest link confidence

The story, report by report

Spacing grows with the time between reports.

  1. First warning

    Keith Murphy↗

    25 Mar 2015 · Simon Wickens · Surrey

    “Action is required to ensure that Prison Officers and Staff with direct access to prisoners have basic first aid training, CPR training and familiarisation with the use of a defibrillator.”
    Original on judiciary.uk ↗

    His Majesty's Prison and Probation Service responded, stating 1 specific action.Response (PDF) ↗

    “all but two of the CMs at the prison have been trained, and those two members of staff will be provided with training as soon as they return to duty. HMP Coldingley also uses a monthly closedown of the prisoner regime to provide opportunities for training for the wider staff group and this includes instruction on CPR and on the use of defibrillators.”

    Stated timescale: as soon as they return to duty

    Web search (Tavily): No evidence found either way

    First Aid, CPR and AED Courses ↗
  2. 4 months later

    Raised again · 1st time

    Luke Myers↗

    20 Jul 2015 · Andre Rebello · Liverpool

    “During the course of the inquest evidence was heard from two members of Prison discipline staff that they had last been trained in first aid respectively 10 and 6 years ago”
    Original on judiciary.uk ↗

    His Majesty's Prison and Probation Service responded, stating 2 specific actions.Response (PDF) ↗

    “staff in the Offender Management Unit at HMP Liverpool have reviewed the sentence calculations for the current population and found no other prisoners to have a miscalculated sentence.”
    “first aid training is being provided to all Custodial Managers who carry out orderly officer duties, ensuring that there will be an additional trained member of staff on duty at all times, and Operational Support Grade staff will also be trained.”
  3. 1 year 8 months later

    Raised again · 2nd time

    John Williams↗

    28 Mar 2017 · ME Hassell · London Inner (North)

    “The prison officers did not have even the most basic first aid and cardiopulmonary resuscitation (CPR) training.”
    Original on judiciary.uk ↗

    His Majesty's Prison and Probation Service responded.Response (PDF) ↗

  4. 9 months later

    Raised again · 3rd time

    Mark Doyle↗

    18 Dec 2017 · Heather Williams · London Inner (North)

    Identical hazardConfidence 0.90 · higha different coroner
    “(4) There is no mandatory first aid training for existing (as opposed to new) prison officers.”
    Original on judiciary.uk ↗

    Repeated from the earlier report:firsttrainingprisonofficers

    His Majesty's Prison and Probation Service responded.Response (PDF) ↗

  5. 10 months later

    Raised again · 4th time

    Nicola Lawrence↗

    23 Oct 2018 · Jonathan Leach · West Yorkshire (East)

    Identical hazardConfidence 0.90 · higha different coroner
    “Some Prison staff had not received any cardiopulmonary resuscitation training. Either as part of initial training or any refresher training.”
    Original on judiciary.uk ↗

    Repeated from the earlier report:Prisonstafftraining

    His Majesty's Prison and Probation Service responded, stating 1 specific action.Response (PDF) ↗

    “The Governor at HMP New Hall has reviewed the band/grade and number of staff who need to be trained in first aid, and the number of such staff required on duty at times throughout the day. The prison currently has 40 staff trained in FAW and 48 in EFAW, and these numbers are considered to be sufficient to ensure that an appropriate response can be provided in any emergency situation that may arise at any time.”

    Web search (Tavily): No evidence found either way

    Heartsaver First Aid CPR AED Training for Corrections Officers ↗
  6. 8 months later

    Raised again · 5th time

    Ryan Trimmer↗

    21 Jun 2019 · James Healy-Pratt · East Sussex

    Identical hazardConfidence 0.95 · higha different coroner
    “Prison staff are often first responders to medical emergencies of prisoners, but not all have received first aid training.”
    Original on judiciary.uk ↗

    Repeated from the earlier report:Prisonfirsttraining

    His Majesty's Prison and Probation Service responded, stating 1 specific action.Response (PDF) ↗

    “The Governors of each prison are required to ensure that there are sufficient numbers of staff trained in first aid on duty, and at HMP Lewes at least two trained nurses and one trained member of prison staff are available at all times. Two on-site first aid trainers will be delivering first aid training to staff as part of the prison's monthly training provision, and a one-day refresher course will be introduced to ensure that training levels are maintained. Custodial Managers (the most senior”

    Web search (Tavily): No evidence found either way

    Mental Health First Aid for Corrections Professionals 2026-09-30 ↗
  7. 4 years 8 months later

    Raised again · 6th time

    Liam Turner↗

    5 Feb 2024 · Zak Golombeck · Manchester City

    Identical hazardConfidence 0.90 · higha different coroner
    “It is not mandatory for prison officers to have basic first aid training (which includes the provision of CPR) which is in-date.”
    Original on judiciary.uk ↗

    Repeated from the earlier report:prisonofficersbasicfirsttraining

    His Majesty's Prison and Probation Service responded, stating 1 specific action.Response (PDF) ↗

    “Following evidence heard at the inquest, you have raised some concerns regarding the first aid training for staff, particularly in relation to the use of CPR. Thank you for bringing your concern to my attention. As you are aware, the HMPPS First Aid Policy Framework was re-issued nationally in August 2023. The revised policy highlights the training requirements for Emergency First Aid and First Aid in prisons, including the importance of Governors ensuring that there is an appropriate number of”

    Stated timescale: August 2023

    Web search (Tavily): No evidence found either way

  8. 4 months later

    Raised again · 7th time

    Daniel Beckford↗

    11 Jun 2024 · Priya Malhotra · Inner West London

    “absence of clarity in the first aid training to prison officers on the use of rescue breaths during resuscitation attempts”
    Original on judiciary.uk ↗

    No published response from His Majesty's Prison and Probation Service was found for this report.

  9. 4 months later

    Raised again · 8th time

    Stephen Sleaford↗

    14 Oct 2024 · I M Cartwright · Leicester City and South Leicestershire

    Identical hazardConfidence 0.90 · higha different coroner
    “Evidence was heard that the majority of those prison officers who had commenced in their roles prior to 2018 had no first aid/basic life-saving skills and no ability/training in undertaking cardiopulmonary resuscitation ('CPR').”
    Original on judiciary.uk ↗

    Repeated from the earlier report:prisonofficersfirstcardiopulmonaryresuscitation

    His Majesty's Prison and Probation Service responded, stating 1 specific action.Response (PDF) ↗

    “attention. The HMPPS First Aid Policy Framework was re-issued nationally in August 2023. The revised policy highlights the training requirements for Emergency First Aid and First Aid in prisons, including the importance of Governors ensuring that there is an appropriate number of trained staff on duty at all times. To achieve this, a detailed local first aid risk assessment must be produced to determine the number of First Aiders at Work (FAW) and Emergency First Aiders at work (EFAW) required at an”

    Stated timescale: August 2023

    Web search (Tavily): No evidence found either way

    Workplace First Aid 2026: Are You Compliant? | Garland Training ↗
  10. 9 months later

    Raised again · 9th time

    Azroy Dawes-Clarke (3)↗

    29 Jul 2025 · Ian Brownhill · Kent and Medway

    Identical hazardConfidence 0.95 · higha different coroner
    “Officers who were present during Mr [name redacted] cardio-respiratory arrest had different training with regard to first aid and basic life support.”
    Original on judiciary.uk ↗

    Repeated from the earlier report:Officerstrainingfirstbasic

    His Majesty's Prison and Probation Service responded, stating 1 specific action.Response (PDF) ↗

    “HMPPS are currently undertaking a cell design review which is looking at all aspects of cell design, including furniture and fittings, to ensure it takes account of developments in how prisoners are accommodated and improvements in what is currently available on the market. As part of this review, we will explore the possibility of using different materials which meet the stringent fire safety requirements and can also function as anti-ligature for bedding. The review is expected to conclude at”

    Stated timescale: end of 2026

    Web search (Tavily): No evidence found either way

    Made in Prison – Understanding knowledge exchange, co ... ↗
  11. 6 months later

    Raised again · 10th time

    Gareth Chumber-Kelly↗

    9 Feb 2026 · Jonathan Stevens · North London

    Identical hazardConfidence 0.95 · higha different coroner
    “The Governor of the prison told the court that no refresher CPR training had been provided to prison staff since 2023 notwithstanding the 5 deaths of prisoners by ligature suspension that have occurred since.”
    Original on judiciary.uk ↗

    Repeated from the earlier report:prisontrainingstaffprisoners

    His Majesty's Prison and Probation Service responded.Response (PDF) ↗Response (PDF) ↗

  12. 3 months later

    Raised again · 11th time

    George Haldenby↗

    21 May 2026 · Rachael Griffin · Dorset

    Closely relatedConfidence 0.92 · higha different coroner
    “After prison officers and prison staff carry out their induction training which covers basic first aid training including the delivery of cardio pulmonary resuscitation (CPR), there is no further mandatory refresher training on first aid or CPR.”
    Original on judiciary.uk ↗

    Repeated from the earlier report:prisonofficerstrainingfirstmandatory

    His Majesty's Prison and Probation Service responded.Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗

  13. All reports to His Majesty's Prison and Probation Service

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This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error